Director, Utilization Management, RN - ONSITE - Kelsey Seybold Clinics

About the Role

Provides executive leadership, strategic direction, and comprehensive operational oversight for all Utilization Management functions, including inpatient utilization review, outpatient prior authorization, concurrent review, retrospective review, medical necessity determination, physician review processes, administrative utilization support, delegated health plan requirements, regulatory reporting, and related clinical and non-clinical operations.

The Director is accountable for ensuring all Utilization Management activities are performed accurately, timely, professionally, and in compliance with CMS, Texas Department of Insurance, NCQA, URAC, delegated health plan, contractual, accreditation, and organizational requirements. Serves as the primary departmental subject matter expert for all clinical, administrative, regulatory, operational, policy, reporting, universe, audit, and delegation-related Utilization Management requirements.

The Director is expected to independently maintain sufficient knowledge of all areas within Utilization Management to provide authoritative interpretation, direction, approval, and oversight without relying on managers, supervisors, staff, or other departments. Maintains direct accountability for the review, interpretation, implementation, and approval of all regulatory bodies and payer technical specifications applicable to Utilization Management, including the review, validation, reconciliation, sign-off, and approval of all Utilization Management universes and related regulatory submissions.

Ensures reporting methodologies, data definitions, inclusion and exclusion criteria, source-system logic, and submission requirements are understood, documented, and applied consistently. Maintains sole departmental ownership and accountability for the development, professional drafting, review, revision, approval coordination, implementation, and ongoing maintenance of all Utilization Management policies, including clinical and administrative policies. The Director is responsible for ensuring all policies are current, accurate, operationally complete, regulatory compliant, professionally written, approved through the appropriate governance process, loaded into PolicyTech, and maintained within PolicyTech throughout the policy lifecycle.

Responsibilities

• Provide executive leadership and strategic direction for all Utilization Management functions.
• Ensure compliance with CMS, Texas Department of Insurance, NCQA, URAC, and other regulatory and accreditation requirements.
• Serve as the primary subject matter expert for clinical, administrative, regulatory, operational, policy, reporting, and audit-related Utilization Management requirements.
• Maintain accountability for interpreting and implementing regulatory and payer technical specifications.
• Oversee the development, review, revision, and approval of all Utilization Management policies.
• Ensure policies are current, accurate, and compliant with regulatory standards.

Requirements

• Bachelor's Degree
• Active Texas Registered Nurse (RN) license or valid multistate compact RN license
• 10+ years of experience in the managed care health insurance field, with 5 years in a management capacity
• Experience analyzing complex regulations, government contract requirements, and policies and procedures

Preferred Qualifications

• Master's degree
• 3+ years of experience in government program managed care/corporate compliance

Benefits

In addition to your salary, we offer a comprehensive benefits package, incentive and recognition programs, equity stock purchase, and 401k contribution (all benefits are subject to eligibility requirements).

Pay

The salary for this role will range from $112,700 - $193,200 annually based on full-time employment. Pay is based on several factors including but not limited to local labor markets, education, work experience, and certifications.